Charlotte* got in touch with our specialist team a few months after her husband Freddie’s* passing to seek representation in his inquest and get our help with understanding if the care he received contributed to his suicide.
Freddie had no previous history of mental health illness or suicidal tendencies until a few months before his passing.
Two months before his death, Charlotte contacted Freddie’s GP to raise concerns about a decline in his mental health. Freddie had a consultation with the practice Mental Health Practitioner around a week after where he discussed his financial worries and he that had felt suicidal a few days earlier but held back from fully acting on it when thinking about his family.
Freddie was referred to the Crisis Team and prescribed an antidepression medication.
The Crisis Team was quick to get in touch and a mental health practitioner visited the couple’s family home the day after. Freddie was found to be in low mood, not interested in food and drink, had been suffering from suicidal thoughts with plans, excessive sleep, and thoughts of letting his family down. He was noted to be hopeless that things would improve but cited his family were a protective factor even though he felt overwhelmed. The crisis team decided during this assessment that a hospital admission was deemed not appropriate, but after a multi-disciplinary team (MDT) discussion that took place it was decided to prescribe additional medication for Freddie and increase the dose.
The next day, a second MDT about Freddie took place where it was it was noted that he did not require a review, to continue with prescription and return for a further MDT review around a week later.
The next few weeks unfolded in a similar way. Freddie cancelled a meeting with the crisis team claiming he had a lot on the day and subsequent cold calls and a home visit found him struggling and in a state of very low mood with feelings of worthlessness.
By this point around a month had passed since Charlotte had initially contacted Freddie’s GP with her concerns. After a home assessment with a Mental Health Practitioner, Freddie was discharged on the basis that crisis support was no longer required as he had a strategy to aid recovery and had a referral for counselling. At a follow up with his GP on the same week Freddie told his doctor that he felt that the initially prescribed medication had been helpful, but he had not taken the additional medication he had been prescribed as it made him feel unwell.
A month later Freddie reached out to the Mental Health Central Access Point, this is a dedicated point of contact for people needing help with their mental health reporting that he was struggling with his mental health again and due to his financial troubles, he was feeling suicidal. He was referred to the Crisis Team who then contacted him the day after. In this last call Freddie reportedly said he was feeling safe, so they tried him again the day after but got no reply. Sadly, Freddie committed suicide by hanging later this day.
Charlotte’s fight for justice
As a result of Freddie’s death a Serious Investigation was undertaken with the following recommendations made for both the Crisis Team and Central Access Point.
The Crisis team should consider having a more consistent approach to who contacts vulnerable people to help build a trusting therapeutic relationship and avoid forcing them to repeat multiple times what has led to them feeling low as needing to repeat that history multiple times can be very hard for people who may be feeling a lot of guilt and shame. All staff should read notes before calls or visits to reduce this. They should also have an MDT discussion before signing off on discharging someone from their service.
The Central Access Point should review their resourcing and ensure that urgent cases like Freddie’s are dealt with promptly even if they reach out for help during the evening instead of waiting for a call back the day after. Also, the call handlers should be empowered to follow up more directly, contact the next of kin where needed and make multiple attempts instead of giving up when someone doesn’t respond to their call. Finally, assessments should be prioritised based on how urgent they are depending on the vulnerability of the supported person.
Freddie’s Inquest
Freddie’s inquest was partly held and postponed three times for various court reasons which of course did not make things easier for Charlotte and the family. It took place a year and a half following Freddie’s passing.
Upon our request for a Prevention of Future Deaths (PFD) report by the coroner they confirmed that the same request had been made for the same Trust a year ago as the result of another person having taken their life. The coroner was highly critical of the trust for failing to put the changes into place as per the PFD recommendations.
Next steps
Following receiving the inquest findings we are supporting Charlotte make a medical negligence claim against the Trust for the care they provided to Freddie.
Several opportunities to effectively reach out to him were lost which we feel contributed to his worsened mental health state and preventable death. Freddie was the sole income provider in the couple and financially supported his children.
We hope that by sharing their story we will empower more people to speak out when they don’t receive the support they need in relation to their mental health. We will remain in Charlotte’s corner to make sure she sees justice for Freddie and to do whatever we can for their story to not be repeated.
Getting support
If you are struggling with your mental health and have suicidal thoughts, it’s crucial to seek help immediately. There is support available, and you do not have to struggle alone.
If your life is in immediate danger, or if you have seriously harmed yourself (e.g., by taking an overdose), call 999 or visit A&E as urgently as possible. Alternatively, for urgent help that is not a life-threatening emergency, you can call NHS 111. They can provide advice and direct you to the right local mental health services, and you may be able to speak with a mental health professional over the phone.
If you have concerns that the care your loved one received contributed to their passing call us on 0800 044 8488 for a free, completely confidential and no obligation discussion or fill in our contact form so we can call you back at a time convenient for you.
*names changed